Please do NOT use the claim forms posted here to submit a claim for over-the-counter (OTC) COVID-19 tests. Please see the section below that outlines the process for those claims.
Use our forms to help manage your health plan and flexible spending account (FSA). If you have any questions, contact Customer Service using the number on your ID card.
Claim Forms
Medical
Mail this form to the address listed on the back of your member identification (ID) card.
Dental
Mail this form to: Medical Mutual, P.O. Box 6018, Cleveland, OH 44101-1018
Vision
Mail this form to: Medical Mutual, P.O. Box 6018, Cleveland, OH 44101-1018
Prescription Drug Claim form for Major Medical Benefits
For members with one deductible for both covered medical and prescription drug claims. Please Note: Use this form only if you forgot your ID card at time of purchase. You will maximize your benefits and be guaranteed the lowest price when you use your ID card at time of purchase.
Prescription Drug Claim form for Drug Card Benefits
For members with separate deductibles for covered medical claims and covered prescription drug claims. Please Note: Use this form only if you forgot your ID card at time of purchase. You will maximize your benefits and be guaranteed the lowest price when you use your ID card at time of purchase.
Prescription Drug Claim form for Drug Card Benefits (on exchange)
For members who bought a plan on the federal exchange and have separate deductibles for covered medical claims and covered prescription drug claims. Please Note: Use this form only if you forgot your ID card at time of purchase. You will maximize your benefits and be guaranteed the lowest price when you use your ID card at time of purchase.
Over the Counter (OTC) COVID-19 Test Reimbursement Claim Form (log in to My Health Plan)
On Jan. 10, 2022, health insurance plans, like Medical Mutual, received additional guidance from the federal government regarding making FDA-approved/authorized OTC COVID-19 tests available to our members at no cost to them starting Jan. 15, 2022. The guidance calls for coverage of 8 tests every 30 days per member. For more information on how you can request reimbursement for any tests you purchased on or after Jan. 15, log in to My Health Plan.
FlexSave Health Care and Dependent Care
Please Note: Your plan must be administered by Medical Mutual Services to use this form.
FlexSave Parking and Transportation
Please Note: Your plan must be administered by Medical Mutual Services to use this form.
Miscellaneous Forms
Adult Dependent Form
Mail this form to: Medical Mutual, P.O. Box 943, Toledo, OH 43656-0001
Disability Verification
Mail this form to: Medical Mutual, 2060 East 9th Street, Cleveland, OH 44115-1355
FlexSave Direct Deposit Form
Please Note: Your plan must be administered by Medical Mutual Services to use this form.
Prescription Drug Mail Order Form
This form is for members with prescription drug benefits through Express Scripts.
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